Several Strategies Can Increase Medication Adherence

A spoonful of cognitive-behavioral therapy (CBT) makes the medicine go down, three clinicians told listeners at APA's annual meeting in Washington, D.C., last month.

Episodes of CBT during brief pharmacotherapy sessions offer psychiatrists the chance to improve medication adherence, lessen symptoms of anxiety or depression, and help patients manage dysfunctional thinking about their illness and its treatment, they said.

Such “high-yield interventions” can make use of a long list of possible tools, from exposure therapy to problem-solving techniques to written goals, among others, said Donna Sudak, M.D., Judith Beck, Ph.D., and Jesse Wright, M.D., Ph.D. Clinicians can choose at each session from the treatment menu based on the patient's diagnosis, symptom severity and complexity, and the phase of treatment.

CBT can be used in any of several contexts, said Wright, a professor of psychiatry at the University of Louisville. For a typical case of bipolar disorder, he may see the patient once for an evaluation, then another seven or eight times for therapy sessions of standard length, followed by shorter maintenance therapy visits that include CBT. Alternatively, he may refer patients to a social worker for standard-length sessions and see them less frequently to monitor medications and do some CBT.

Adding CBT to a medication check is more than a clinical bonus, said Sudak, an associate professor of psychiatry at Drexel University. A CPT code (90843) covers a 20- to 30-minute session combining therapy and medication review.

Patients may have both practical problems (that is, financial or access problems) and psychological problems in adhering to their medication regimen, said Beck, an associate professor of psychiatry at the University of Pennsylvania. Adherence might be tied to cultural or religious beliefs about illness or medication use. Some patients may tell themselves that“ medications are a last resort”—and then don't fill the prescription. When patients say they have a 50 percent likelihood of taking their meds every day, that may mean they aren't taking them at all, she said.

Physicians, too, may contribute to poor adherence if they see writing the prescription as the end of their responsibility or hold rigid ideas of how patients should act.

To overcome these barriers, Beck suggested strengthening the therapeutic alliance.

“explain the rationale for the drugs and link the medications to the patient's own goals, like getting back to work or improving relationships,” she said. “Include family members and have the patient write down the discussion.”

Identify the barriers to adherence, then find solutions, said Wright. Tying pill taking to some specific daily activity like toothbrushing may simplify the thinking needed to take drugs consistently.

“The point is to get the patient on board,” said Wright.“ Figure out why the patient won't do the meds, show empathy, and spend time responding.”

Beck suggested that clinicians be alert to affective responses and probe the automatic thinking that derails medication use: “When you didn't take your medications, what were you thinking?” Writing down those dysfunctional thoughts on “coping cards” makes them easier to discuss. In fact, written discussions and goals are key tools. Some practitioners use index cards, plain sheets of paper, or cheerfully preprinted notes. Some patients bring along “therapy notebooks.” Wright sometimes hands over his prescription pad to the patient and asks, “What would you prescribe?”

Writing down a schedule of pleasant, meaningful activities can help patients with depression defeat the tendency to withdraw and fall back into reminders of their illness. Picking one or two concrete, achievable events turns the exercise into a no-lose proposition when coupled with a brief discussion of predictable obstacles and ways to avoid them. If an activity doesn't work out and the patient feels worse, don't treat the event as a failure, advised Wright. “Look at the barriers, and also ask yourself whether you prepared the patient properly.”

Combining medication with behavioral interventions may also resonate with views expressed in the popular media, said Beck. The idea that medication alone is not enough to alleviate symptoms opens the way for more patient involvement.

Patients with anxiety may benefit from exposure and response exercises, cognitive restructuring, relaxation training, or breathing training to calm themselves during a panic attack.

These can be discussed in the office but carried out between visits. Exposure therapy for someone with a fear of cooking and serving food might begin with a five-minute exercise heating a frozen dinner in the microwave, then advance through a dozen lengthier and more complex steps up to cooking Thanks-giving dinner for the entire family—an example Wright drew from his own practice.

Of course, not all of these interventions would be used in any single visit, said Sudak.

“The doctor has to decide on the fly which intervention will be most helpful to talk about that day,” she said. “Save another approach for the next time.”

Empathy and a strong therapeutic alliance are keys to motivating patients, but they look for a therapist to be a “friendly teacher,” not a friend, said Sudak. ▪